Maurie Markman, MD
The state of oncology in the United States today is on the verge of chaos. At a time of stunning advances in our understanding of the fundamental mechanisms responsible for the establishment and progression of malignant disease and of the process of inherent or acquired drug resistance, along with the development of increasingly effective molecularly targeted and immune-based therapeutics, a simply unsustainable nancial model threatens to dismantle our poorly coordinated and distressingly fragile cancer care delivery system.
Consider, for example, a recent report suggesting that the total cost associated with the optimal management of chronic lymphocytic leukemia (CLL) in the United States will increase to $5.13 billion by 2025, a 6-fold increase from $0.74 billion in 2011. This forecast estimates the “cost of success” in CLL, with novel agents entering the oncologist’s armamentarium that have the potential to improve both the quality and quantity of life for patients with this relatively common malignancy. But how can individual patients, families, and society continue to afford the staggering costs of novel effective treatments?
The intent of this commentary is not to attempt to answer this critically important yet profoundly complex question, but to focus on a component of the cancer care continuum that has the potential to favorably impact the rapidly encroaching crisis in cancer care costs at the societal level.
Regardless of whether we are talking about a developed or a developing country, it is essential to acknowledge approaches to cancer care that have been documented or strongly suggested to be effective in the prevention of malignant diseases and that do not require expensive technology or drugs. Although the 3 strategies highlighted in this commentary may sound to some like a broken record, a truly sustained focus on low-cost measures that can favorably reduce cancer incidence becomes ever more relevant in light of the relentless escalation in the costs associated with care of a confirmed malignancy.
Targeting Tobacco Use
Of course, the No. 1 item on any list of interventions must be a renewed emphasis on effective strategies for tobacco control. Currently, it is estimated that approximately 17% of all adults in the United States smoke cigarettes, and that 1 in 4 high school students use tobacco products. Furthermore, recent data suggest that at least 167,000 deaths in the United States in 2014—or a truly staggering 28.6% of all cancer deaths—were related to cigarette smoking. And, one must add to this figure an unknown number of smoking-related cancers resulting from second-hand smoke exposure.
If the minimum legal age for access to tobacco products were increased from the current threshold of 18 years to 21 years, public health experts estimate that there would be a 25% reduction in the initiation of smoking by adolescents. The impact of this change would translate into an overall 12% reduction in cigarette smoking rates and 45,000 fewer deaths from lung cancer among individuals born between 2000 and 2019. One can only speculate on the added number of deaths and costs associated with the treatment of other smoking-related cancers that would be avoided by implementing this simple regulatory approach.
Although it must be acknowledged that all efforts to reduce cigarette smoking would be strongly opposed by the powerful tobacco lobby, legislators need to be constantly reminded of both the individual impact of tobacco-associated cancers (and other serious medical conditions) and the enormous financial burden this addiction imposes on families and society.
Strategies to Fight Obesity
The second area to highlight is the increasingly recognized, rapidly progressing, and extremely worrisome epidemic of obesity (defined as a body mass index >30) in the United States, estimated to include 38% of all adults, and its impact on the development of cancer. The risk of certain malignancies, such as liver, esophageal, gastric, colon, pancreas, endometrial, gall bladder, and postmenopausal breast cancers plus multiple myeloma is considerably greater for obese patients compared with normal weight individuals, and mortality may also be increased.